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Fourth Case of Chronic Traumatic Encephalopathy Reported in Former NFL Player

ARTICLE IN BRIEF

✓ Pittsburgh Steelers offensive lineman Justin Strzelczyk, who died in a car crash three years ago at age 36, is the fourth former football player diagnosed with chronic traumatic encephalopathy based on autopsied brain tissue.

At 6 feet 6 inches and 291 pounds, former Pittsburgh Steelers offensive lineman Justin Strzelczyk was a force to be reckoned with. But when University of Pittsburgh neuropathologist Bennet Omalu, MD, conducted a post-mortem examination on his brain, the image appeared to come from an 80-year-old man.

Strzelczyk, who died in a car crash three years ago at age 36, is the fourth former football player that Dr. Omlau has diagnosed with chronic traumatic encephalopathy (CTE), a condition marked by neurofibrillary tangles and neuritic threads in the neocortex that progress to the hippocampus. This case, first reported on June 15 by TheNew York Times, is the latest to question whether football concussions cause long-term brain damage.

“What this disease is looking like is tangle-only dementia, which of course, only people in their 80s and 90s get,” Dr. Omalu told Neurology Today.

In January, Dr. Omalu reported that multiple concussions caused severe anatomic pathology in the brain of former Philadelphia Eagle Andre Waters, who committed suicide in November 2006 at age 44. Dr. Omalu has also reported CTE in the brains of ex-National Football League (NFL) players Terry Long and Mike Webster (Neurosurgery 2005;57:128–134; Neurosurgery 2006;59:1086–1093).

Adding to the controversy, former New England Patriots middle linebacker Ted Johnson, 34, announced in January that he suffers from depression and cognitive impairment stemming from two successive concussions.

Unlike Waters, Long, and Webster, Strzelczyk did not have any documented concussions, Dr. Omalu said. Nevertheless, he is convinced that the neurofibrillary tangles and neuritic threads he observed in Strzelczyk's brain tissue are the result of multiple head blows. “It's not possible for a football player to play for eight to 10 years without sustaining even one concussion, even one high impact blow to the head,” Dr. Omalu said. He offered this example: according to NFL records, Waters had experienced only one concussion, yet when asked about his career concussions in an interview with The Philadelphia Inquirer in 1994, Waters said he had “lost count at 15.”

Dr. Omalu's findings on Strzelczyk and Waters have not been published in a medical journal, although he said he has submitted papers for review. Ronald Hamilton, MD, of the University of Pittsburgh, and Kenneth Fallon, MD, of West Virginia University, also examined Strzelczyk's brain tissue biopsies and concurred with the diagnosis.

CTE is a progressive disease, Dr. Omalu said. He pointed out that Strzelczyk's neurofibrillary tangles and neuritic threads were fewer and more dispersed than Waters, who was eight years his senior.

“This is not AD and this is not dementia pugilistica because these players are not boxers,” Dr. Omalu said. “This is football-induced chronic traumatic encephalopathy. In the paper we're submitting we're proposing this be recognized as a separate entity.”

NFL CONFERENCE

Strzelczyk's case was reported just four days before the NFL's first-ever conference on mild traumatic brain injury in June. The Chicago meeting was attended by NFL trainers and physicians, as well as outside experts who have criticized the way the league manages concussions.

Julian Bailes, MD, chair of neurosurgery at West Virginia University, and a former team physician for the Pittsburgh Steelers, discussed Dr. Omalu's research at the meeting. Dr. Bailes, who knew Strzelczyk personally, suspected the athlete may have had CTE and suggested Dr. Omalu investigate.

At the meeting, Dr. Bailes also discussed the results of concussion studies he co-authored with colleagues at the University of North Carolina's (UNC) Center for the Study of Retired Athletes. In a June 7 study, UNC researchers reported that retired NFL players who recalled three or more concussions have triple the risk of being diagnosed with depression than those who recalled none (Med Sci Sports Exerc 39:903–909). They surveyed more than 2,500 retired NFL players.

Dr. Bailes said conference attendees were receptive to both presentations. “I'm optimistic that some very positive steps have been taken. We have to wait and see how they [the NFL] interpret this and how they may, if at all, change their policies.”

Ira Casson, MD, a New York City neurologist who co-chairs the NFL committee on mild traumatic brain injury, agreed that the conference was productive. “Any scientific disagreements that occurred were discussed in a frank, open, scientific manner without any personal attacks.”

He added that “there is a lot more common ground between some of the things the committee has done and some of the things critics of the committee have said” than has been presented to the media.

As a result of the meeting, the committee might look into the issue of depression amongst NFL players. “We are considering consulting with psychiatrists and other mental health professionals who have expertise in the field of depression in athletes or depression following head injury,” Dr. Casson said.

As for the Strzelczyk case, Dr. Casson said he would not comment because he doesn't think “it's appropriate for scientists to be discussing information that has not been presented in the scientifically appropriate manner in a scientific journal.”

In May, new NFL Commissioner Roger Goodell announced new standards for managing concussion, including mandatory neuropsychological baseline testing for all players. [See sidebar, “New NFL Concussion Standards.”] Dr. Bailes said baseline testing is important because the effects of concussion are not always evident in brain scans.

In addition, the NFL is conducting its own study on the neurocognitive effects of concussion. Over 120 players who retired from 1984 through 1996 will undergo clinical neurological evaluations, brain MRIs, and psychological tests, the results of which will be compared with the number of reported concussions. Controls will include men who played football in high school and college, or who played less than one season with the NFL.

SPORTS LEGACY INSTITUTE

In the meantime, Drs. Omalu and Bailes are working to form an organization called the Sports Legacy Institute, which will conduct research on the long-term health effects of sports on athletes. Christopher Nowinski, a former professional wrestler who works with Dr. Omalu and is the author of Head Games: Football's Concussion Crisis (2006), is heading the project. He said the group will initially focus on approaching families for permission to conduct brain analyses of deceased former athletes. The nonprofit organization will be university affiliated, although a location has not yet been chosen, he said.

They hope to obtain enough brain tissues to create a databank that will allow researchers to sort out genes that might predispose some players to the long-term effects of concussion, Dr. Omalu said. Already, several families of former athletes have contacted the group, he said.

For Nowinkski, one of the goals is for the NFL to take concussion seriously. “I'll consider myself a failure if they don't drastically change their policies within the next 12 months,” he said.

New NFL CONCUSSION STANDARDS

On May 22, the NFL announced a new concussion management plan:

* Medical decisions must always override competitive considerations.

* Standardized neuropsychological baseline testing will be required for all NFL players beginning this season. It cannot be used by itself to make clinical decisions. For players removed from games due to concussions, repeat testing will be done during the seasons to track recovery and to help decide when they can return to play.

* To promote the use of best practices by all teams, the evaluation procedures used by NFL teams will be shared among all medical and training staffs.

* A brochure will be developed and distributed to NFL players to help educate players and their families about concussions, including how to recognize the symptoms of a concussion and recommended treatment procedures.

* Return-to-play decisions should continue to be made by team medical personnel using their expertise and professional judgment.

* The NFL rule requiring every player to wear a chin strap that is completely and properly buckled to the helmet will be strictly enforced. Teams and players will not be permitted to modify the attachment of the chin strap to the helmet or improperly modify the helmet in any other way. The longstanding safety-related rules to the use of the helmet also will be strictly enforced.

* The NFL will establish a “whistle blower” system so that anyone may anonymously report any incident in which a doctor is pressured to return a player to play from a concussion or that a player with a concussion is pressured to play. The NFL will investigate any such reports and take whatever action is necessary.

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